2. PwC
With you today
2
PricewaterhouseCoopers LLC
300 Madison Avenue
New York, NY 10017
simon.samaha@us.pwc.com
Simon Samaha, MD
Principal Client Services
Co-lead- Care Delivery
Transformation Practice
Health Industries Advisory
3. PwC
Goal for today: what we are seeing in the market?
Alignment between EHR implementation and Transformation
• TCO vs Value Based Implementation
• Transformation discipline
• Using professional services
3
4. PwC
Table of contents
4
What are we seeing in the market: Implementation vs.
Transformation
How do we define Value Based Implementation?
How are transformation and EHR
aligning?
Using Professional services
1
3
4
2
5. PwC
What are we hearing?
• Was unable to deliver and show
value beyond a smooth go live
Client CIO
Go Live went on time, on
budget and on scope; CEO not
happy
“
• Addressed technology in
isolation of People and Process,
but more important there was no
value proposition but TCO which
included software related benefit
realization
”
5
Our clients need
optimization help after go live,
in revenue growth,
productivity, physician
productivity, governance, and
other operational challenges
“
”
Vendor Executive
1-Implementation vs Transformation
6. PwC
Typical Business Case:
Technology Acquisition Cost
+ EHR Implementation Cost
+ Software/Hardware Maintenance Cost
= Total Cost of Ownership (TCO)
Typical TCOs lack consideration for
care delivery transformation needed
during and post go live
Value-Based Business Case:
Technology Acquisition Cost
+ EHR Implementation Cost
+ Software/Hardware Maintenance Cost
+ Care Delivery Transformation
+ Post-Implementation Transformation
= Total Investment
+ Value Realized
= Net Benefit
A new starting point? TCO vs. Value Based Implementation
Starting with the business case
6
1-Implementation vs Transformation
7. PwC
How is Value-Based Implementation (VBI)
different from ROI
ROI VBI
•Justifies initial investment
•Rarely used post-implementation
•Drives benefits realization
•Scope extends beyond system activation
•Typically based on operational metrics –
•FTE reduction
•Patient Satisfaction
•Value realized is based on strategic & measureable
value –
•Cost of care reduction
•Patient retention
Vs.
7
1-Implementation vs Transformation
8. PwC
Bu
EHR implementations have failed to deliver value
because there has been no focus on value creation
Go Live
Focus
Value-
Based
Focus
Features &
Functions
Scope Time
Line
Technology
Implementation
Identify
Value
Budget
Validate
Value
Drive Value
with
Transformation
Budget
Care
Transformation
Implementation
A Value-Based Implementation focuses on achieving value
rather than just system “activation”
Traditional implementation vs. Value based focus
8
1-Implementation vs Transformation
9. PwC
Selection Implementation Go Live
Value
Proposition
Execution Sustainability
Value Based Implementation requires a
transformation approach
Best perceived system
based on features and
functions
PMO driven focusing
on Scope, Timeline
and Budget
Success = System go
live with limited if any
downfalls
EHR Implementation
Determine value to be
achieved.
Execute changes in
People, Process and
Technology
Assure value created
is achieved and
sustained
Transformation
Achieving a transformation through an EHR implementation requires
both, question is how are these 2 aligned and synchronized?
Value realized
= TCO +/-
Implementatio
n benefits
Value realized
= Value
proposition +
sustainability
9
1-Implementation vs Transformation
10. PwC
Transformation : eliminate non
value added functions
New Care Delivery Model: Patient
focused affinity & democratization of
care
Customer Relationship Management
Precision medicine
Virtual visits
Operationalization: put in place
Operating model
Call centre
Service line implementation
Scope of practice analysis
Technology: EHR implementation/
standardization
Optimization: get the most
Team-based “continuity of care”
design
Physician Enterprise enhancement
Cross department scheduling
EHR optimization
Enterprise interoperability
The road to Care Delivery Transformation is a journey, not a
destination
Customer
Engagement
Margin
Management
Clinical
Integration
Workforce
Transition
Predictive
Analytics
Integrated
Technology
Services: A staged approach
10
2- Value based implementation
11. PwC
Tomorrow’s organization will need six broad capabilities to
enable a value based care delivery model
Predictive Analytics
Adaptable models, machine learning, new and informed data sources, using data to predict and guide financial and clinical
outcomes, agile responses to quality and risk pressure
Clinical Integration
Connection and integration of clinical and revenue cycle operations, aligning with strategic intent, going beyond population
management and aligning the network
Customer Engagement
Personalized, transparent, convenient, and on-demand
Margin Management
Standard and efficient operations, shared service models, contract management, convergent practices, supports quality and risk
based reimbursement models
Workforce Transition
Organizational alignment, Integration of clinical and revenue cycle resources, improved critical thinking skills, new staffing models
Integrated Technology across the Continuum of Care
Appropriate use of workflow driven technologies that minimize human intervention to drive results, easy access to data for all
stakeholders
11
2- Value based implementation
12. PwC
EHR Before
Transformation
Transformation
Before EHR
EHR &
Transformation
When it comes to aligning EHR implementations and
transformation, what are the perceived pros & cons?
12
Technology platform available for
transformation
Focus and align with overall
Transformation
Full synchrony and ability to cover
People, Process and Technology
Implementation not in line with
Transformation, and risk of re-
implementation
Technology platform not available
for transformation
Too complex to handle, HIT
vendors typically recommend and
push for a transformation after
2- Value based implementation
13. PwC
Let us take an example: Physician productivity
• Typical concern is around physician
adoption and impact on physician workflow
• EHR scope focuses on different but related
areas
• Physician: ease of use, screen design,
adoption, workflow
• Registration: ease of registration
• Back end: proper billing
• We do see in benefit realization increase or
no decrease in productivity
• In most instances we see decrease in some a
25% decrease for > 6 months
• What drives this disconnect are:
• Lack of true value proposition
developed but rather ability of a
system that may or may not be
sufficient to solve the problem
• Focus is still on activation first and
benefit later
Pre-
encounter
Post-
encounter
Encounter
• Proper deployment
• Understand supply-
demand
• Front end
• Back end
• Patient engagement
• Patient reactivation
• Throughput
• Predictability of
schedules and
experience
* Covered or at least partially addressed by EHR
• Governance
• Incentives
• Operations
13
2- Value based implementation
14. PwC
How are transformation and EHR
implementations aligning?
Determine
Value
Proposition
Develop a
Roadmap
Align scope &
timeline between
EHR and
Transformation
Implement EHR
under
transformation
discipline
Manage
Risk
•Develop a corporate
wide value proposition
•Validate and determine
feasibility
•Ideation and details of
current and future state
•Stakeholder buy in
•Risk and sustainability plan
•Scope
•Sequence
•Budget
•KPI and realization
•Common oversight
•Maintain overall PMO with
a subset on EHR
•Embed risk
management and
controls based on
future state
14
3- Aligning Transformation and Implementation
EMR implementation
begins
Transformation begins
15. PwC
Cost of care: identifying variability by service line
$-
$1
$2
$3
$4
$5
$6
$7
Millions
Value of variability by service lines based on Medicare FFS data
Source: Medicare FFS Data
15
Determine
Value Prop
Align
Scope
Transform
with EHR
Manage
Risk
Develop a
Roadmap
17. PwC
Roadmap
Access
• Current state: we offer centralized and cross
departmental access
• Future state: we will perform predictive scheduling on
all of our primary care, OB, Peds PC, and chronic
disease patients. We will also offer virtual visit based on
predictive outreach to the patient and family
• Stakeholders: physicians, centralized access, Revenue
cycle, Risk management
• Financial impact:
- Increase in patient affinity xxMM$
• Sustainability plan:
- KPI: n of patient with predictive call/(n of patients with
predictive call + n of patient with patient/family initiated
call)
• Risk:
- Reimbursement
- Cost of care increase/excess utilization
EHR implications:
• Rules and data for predictive scheduling
• Rules for virtual v/s real encounter
• Virtual visit type and reimbursement
• Virtual visit workflow and EHR intake
• Patient access to EHR for data and digital (device
entry)
• Rules for follow up on patients after a virtual
encounter
• Quality controls for virtual visits
Centralized Access
Cross departmental
scheduling
Predictive Scheduling
Virtual visit
Current state
Future state
17
Determine
Value Prop
Align
Scope
Transform
with EHR
Manage
Risk
Develop a
Roadmap
18. PwC
Roadmap
Pharmacy Stewardship Program
• Current state: we have a strong P&T committee
addressing clinical indication
• Future state: we will increase the scope to include
pharmaco-economic decision, and use medication
profile as one of the drivers of care management
• Stakeholders: physicians, pharmacy, P&T, Finance,
Population health
• Financial impact:
- Decrease cost of care for patients with annual medication
cost > $1,000
• Sustainability plan:
- KPI: Expected v/s actual cost.
- Change in P&T governance model
• Risk:
- Impact of change of governance
- Physician adoption
- Impact on research
- Conflict with disease based care management
EHR implications:
• Cost and pharmaco-economic embedded in
medication profile
• Rules and Alerts
• Medication profile registries
• Medication profile care management workflow
• Rules and alerts specific for overlapping clinical
conditions
• Pharmacist workflow
Clinical P&T
Add Pharmaco-economic
decision
Use medication profile as one of
the drivers care management
Current state
Future state
18
Determine
Value Prop
Align
Scope
Transform
with EHR
Manage
Risk
Develop a
Roadmap
19. PwC
Roadmap
Order Set Usage
• Current state: we use admission order sets to drive
standardization of care and educate our students and
residents on proper care and best practices
• Future state: we will use order sets to test the
knowledge level of our students and residents
• Stakeholders: students, residents, fellows, physicians,
research , residency program directors,
• Financial impact:
- Precursor to better clinical education effectiveness
• Sustainability plan:
- Measure knowledge and impact of interventions
- Feedback from residents and students
• Risk:
- Slow down ordering process
- Physician adoption
EHR implications:
• Design of order set
• Capture usage and usage time
• Develop or partner for knowledge testing material
• Embed knowledge testing for residents and students
• Capture results and link to educational interventions
• Report on usage behavior and create a learning
analytics tool
Standardized admission
order set
Embed knowledge
assessment in order sets
Current state
Future state
19
Determine
Value Prop
Align
Scope
Transform
with EHR
Manage
Risk
Develop a
Roadmap
20. PwC
Align & implement: methodology
20
Readiness Implement Activate Go Live
IT/EHR
Roadmap Transform Sustain
Transformation
Develop Plan Test Mitigate
Risk
Assurance
Determine
Value Prop
Align
Scope
Transform
with EHR
Manage
Risk
Develop a
Roadmap
21. PwC
Align & implement: Value based transformation
benefits
21
Determine
Value Prop
Align
scope
Transform
with EHR
Manage
Risk
Develop a
Roadmap
Guided by
purpose & vision
and enables Financial
Excellence
which leads to
Physician Alignment
and Team Satisfaction
Vision: highest quality comprehensive continuum of integrated health care
Purpose: increase excellence in care and advance transformative efforts with
their unified voice
through the Value of
Integration
that creates a better
Patient Experience
Drive Care Excellence
• Enhanced care delivery and coordination due to access to single longitudinal
patient record across the care continuum
• Higher clinical efficiency
• Reduced errors and redundancies
• Decreased mortality rates , readmissions, and LOS
• Management of the health of the population: one record, one outcome
• Improved access to providers according to clinical and personal need
• Improved use of technology infrastructure due to integration, usability,
reliability, and stability
• Ease of access to “patient’s complete story”
• Enhanced workforce: resource optimization and team-based care model
• Increased standardization in workflows and processes: assessments,
treatments, preventive services and follow-up care
• Reduced cost: pricing, cost per case etc.
• Enhanced profitability through margin management
1
2
3
4
5 • Enhanced experience of “consistent”, coordinated” and “integrated” care
• Increased consumer participation
• Improved choice
• Enhanced safety of care and services
22. PwC
Putting controls in place: What can go wrong with
an EHR transition…
22
Program
ManagementTechnology
Financial &
Compliance
Clinical &
OperationalOrganizational
RISK EXAMPLES
Patient Care/Experience: Negative clinical outcomes, sentinel/reportable events, and patient dissatisfaction
Economic Risk: Cash flow declines, gross and net receivables increases, increase in DNFB days and amounts, regulatory billing noncompliance (i.e.
fines and penalties), increase in charity care, contractual allowances, and bad debt expense
Financial Statement Risk: EHR sub-ledgers not reconciling to G/L, treasury clearing accounts not reconciled or reconciled with significant balances,
unusual contractual allowance and charity/bad debt fluctuations, and negative audit opinion due to deficient controls impacting bond rating
•Impact of organizational
culture
•Users don’t understand
or struggle to use the
system
•Difficulty recruiting and
retaining staff
•Cost overruns result in
project going over
budget, time and scope
•Cybersecurity/ Privacy
violations
•Patient access challenges
•Increased Patient and
Provider dissatisfaction
•Quality care
compromised due to
unintended
consequences or
omissions
•Workflows not
operational, aligned
and/or conducive to end
users
•Challenge to produce
official medical records
•System doesn’t function
as intended, inaccurate
or incomplete billing
•Revenue cycle
implications and cash
flow disruptions
•Segregation of Duties
violations
•Fraud or financial
statement integrity issues
•Regulatory non-
compliance (e.g.
Meaningful Use)
•System is not available
when needed
•Interoperability:
Interfaces don’t
accurately or completely
exchange information
•Insecure configuration
resulting in data breach
•Access is not restricted or
based on user roles
•Lack of resilience
•Data integrity issues
•Workflow disruptions
•Changes to system are
not managed
•System is not
implemented on time or
on budget
•Ineffective or inadequate
training of physicians
and clinicians or front
line
Determine
Value Prop
Align
Scope
Transform
with EHR
Manage
Risk
Develop a
Roadmap
23. PwC
And What Can Be Done to Prevent it…
End-to-end Process, Risk, and Control workflow design/assessment and
recommendations
Assessment of Governance and Project Management
Control testing and remediation, with resiliency planning and validation
Key regulatory compliance controls integration
Key clinical care and patient safety controls integration
Technology Assurance (e.g. change control and application access controls assessment )
External and internal reporting process assessments of interfaces from EHR
Financial process and related controls testing of design and effectiveness for those
processes impacted from the EHR implementation (e.g. Revenue, A/R and Treasury)
Subsequent go-live implementation reviews and legacy system(s) cutover
To mitigate risk, a risk assurance focused project team will
assist the organization with oversight activities to include, but
not limited to:
23
Determine
Value Prop
Align
Scope
Transform
with EHR
Manage
Risk
Develop a
Roadmap
24. PwC
Engaging professional services: different models at
different stages
Three Types of
Service
Before Selection
During
implementation
After Go Live
Implementation
Typically staff augmentation
providing additional staff to
support implementation and
configuration
Selection & TCO Staff augmentation
Transformation
Senior level with expertise in
EHR and Clinical
Transformation help in aligning
transformation and EHR
implementation
Value proposition and
alignment
Kick off transformation
Support transformation Transition
Risk Assurance
Mostly focusing on revenue cycle,
financial controls, research
compliance
Develop baseline
assessment
Test and assure good
controls
Assure good transition
24
4- Engaging professional services
25. PwC
Value
•Aligned IT Strategy
•System Selection
•Implementation Planning
•Readiness Assessment
•Total Cost of Ownership
•Project Management
•Interim Management
•Application Expertise
•Training Strategy
•Virtual Testing Center
•Standardization
•Evidence based practice
•Clinical Documentation
•Process Redesign
•Revenue Cycle
•System Optimization
•Benefits Realization
•Adoption
•Clinical Informatics
•In Flight Health Check
•Risk & Controls Audit
•Regulatory Compliance
•Data Integrity
•Continuous Improvement
Planning Implementation Transformation Optimization Evaluation
Value is generated by coupling care delivery transformation with technology
implementations to create a sustainable future operating model
Governance Structure, Scope & Decision-Making
Change Management & Communication
Physician & User Adoption
Engaging professional services
25
4- Engaging professional services
26. PwC
Some are using risk based models with professional
services
25% 15%
15% 45%
System Transform
Milestone
Outcomes
40% 60%
40%
60%
Develop component of @Risk based on value
proposition and organizational readiness
26
4- Engaging professional services
27. PwC
Key takeaways
27
01
02
03
04
Focus on a value
proposition before starting
an EHR program
Assign a clinical executive
to own the value based
EHR program
Look at internal
controls right at the
beginning
01
02
03
04
Underestimate the
important of transformation
Forget to drive clinical
ownership of value drivers
Dos Don’ts
Approach EHR as a technology
play
Partner with trusted advisors who
focus on transformation, not
implementation
Forget to understand what value
drivers are behind the EHR program
e.g. service lines
